Experience with fully covered self-expandable metal stents for anastomotic stricture following esophageal atresia repair.

There is a lack of experience with fully covered self-expandable metal stents (SEMSs) for the treatment of benign esophageal conditions in the pediatric population. This is the evaluation of our institutional experience of placing SEMSs for anastomotic stricture (AS) formation following esophageal atresia (EA) repair. Patients were jointly managed from the Department of Pediatric Surgery and Central Interdisciplinary Endoscopy at our institution. Thirteen children (8 male, 5 female) with a median age of 4 months (range: 1-32 months) who underwent treatment with SEMSs for a postoperative AS following EA repair between February 2006 and April 2016 were recruited into this retrospective study. SEMSs that are originally designed for other organs such as trachea, bronchus, biliary tract, or colon were inserted under general anesthesia via endoscopic guidance. Simultaneous fluoroscopy was not required in any case. In five infants, the stents were inserted primarily without previous therapy. Seven patients underwent stenting following dilatation with or without adjuncts (e.g. Mitomycin C, Triamcinolone). In one case with an AS and a simultaneous persistent tracheoesophageal fistula (TEF), multiple SEMSs were applied after failure to close the fistula with fibrin glue.The median duration of individual stent placement was 30 days (range: 5-91 days). In five children up to four different biliary, bronchial or colonic SEMSs were placed successively over time. There were no problems noted at stent insertion or removal. Eight children (62%) developed complications associated with stenting. At follow-up, in eight patients (62%) AS was resolved, including all of those five cases, who had their stents inserted without previous therapy. Five children (38%), who underwent dilatation prior to stenting did not improve their AS and required further intervention. Overall, the cohort exhibited a slight, but not significant weight gain between stent insertion and (final) stent removal.Insertion of SEMSs for AS following EA repair is safe and often successful with only one single application. It can be used as a primary procedure (without previous therapy) or after failed dilatations.There was one death in this study that was unrelated to stenting and occurred 12 months after stent removal. Because of the absence of manufactured, age-related devices, SEMSs that are originally designed for other organs can be applied. Establishment of a standardized management including stent placement for the treatment of AS following EA repair in the pediatric population is required.

[Quality of documentation of intraoperative and postoperative complications : improvement of documentation for a nationwide quality assurance program and comparison with routine data]. / Dokumentationsqualität intra- und postoperativer Komplikationen : Verbesserung der Dokumentation für die verpflichtende Qualitätssicherung und Vergleich mit DRG-Routinedaten.

INTRODUCTION: Complications after cholecystectomy are continuously documented in a nationwide database in Germany. Recent studies demonstrated a lack of reliability of these data. The aim of the study was to evaluate the impact of a control algorithm on documentation quality and the use of routine diagnosis coding as an additional validation instrument. METHODS: Completeness and correctness of the documentation of complications after cholecystectomy was compared over a time interval of 12 months before and after implementation of an algorithm for faster and more accurate documentation. Furthermore, the coding of all diagnoses was screened to identify intraoperative and postoperative complications. RESULTS AND DISCUSSION: The sensitivity of the documentation for complications improved from 46 % to 70 % (p = 0.05, specificity 98 % in both time intervals). A prolonged time interval of more than 6 weeks between patient discharge and documentation was associated with inferior data quality (incorrect documentation in 1.5 % versus 15 %, p < 0.05). The rate of case documentation within the 6 weeks after hospital discharge was clearly improved after implementation of the control algorithm. Sensitivity and specificity of screening for complications by evaluating routine diagnoses coding were 70 % and 85 %, respectively. The quality of documentation was improved by implementation of a simple memory algorithm.

[Castrati--everything to achieve fame]. / Kastraten--alles für den Ruhm.

The phenomenon of castration is wedded to the baroque era. This epoch stands for pure sensual pleasure. Those who could afford it tried to arrange their earthly days to be as enjoyable as possible. A perverse bloom of this ambition was the angel-like voices of the castrati. The supernatural sound of the voice was meant to let the opera visitors escape into another world. High society was almost addicted to those voices. On the other hand nobody showed any interest in the spiritual life of the castrati. Farinelli, Nicolini, and Senesino, three of the most famous castrati, were the first musical superstars of the eighteenth century. Their voices moved the decadent baroque audience to tears and enraptured them to the point of standing ovations. But the price for this fame was high. Only through castration in their early boyhood could this bell-like voice be kept. Because of the sensational success of the castrati, a huge wave of castration swept over Italy. Ambitious parents had their boys castrated, hoping that they would also become famous opera stars. It is estimated that in Italy alone over half a million boys were victims of this mutilating procedure during the eighteenth century. Because castration was officially forbidden it was done"behind closed doors" by untrained barbers and of course was associated with a high morbidity and mortality rate. The height of the castrati ended with the fading eighteenth century. The last castrato, Alessandro Moreschi, was engaged as a chorister and soloist at the Sistine Chapel in the Vatican. He was pensioned off by Pope Pius X in the year 1912 after an official ban on castrated singers was imposed. With that a very impressive part of music history had ended.

Submucosal cushioning with water jet before endoscopic mucosal resection : Which fluids are effective?

BACKGROUND: Several new techniques have recently been described that allow the endoscopic mucosal resection even of broad-based flat lesions in the gastrointestinal tract. The technique recently described by us of using a water jet dissector (Helix HydroJet) for a selective deposition of liquid in the submucosal lamina has now been combined with different substances, and their effects have been compared. MATERIAL AND METHODS: Gastroscopies were carried out in 8 pigs under intubation anesthesia, and 2 submucosal cushions each were created in the stomach using one out of 4 test substances (gelatin, glucose 50, hydroxyethyl starch [HES] 10%, dextran 40), as well as one cushion of isotonic saline solution placed in each area via the Helix HydroJet). The height of the submucosal cushions was intermittently measured over a period of 40 or 20 min, respectively, by miniprobe endosonography. In 7 of the animals the stomach was subsequently subjected to mucosal resection. The specimens and the gastric wall were histologically assessed to evaluate the localization of the liquid cushion and the effect on adjacent layers of the gastric wall. RESULTS: All test substances produced strictly selective liquid cushions in the submucosa. With HES 10% and dextran the maximum height of the cushions initially increased and then decreased during the further course to an average of 90% of the initial height within 40 min. Isotonic saline solution showed the most rapid decrease in height (72% after 20 min). The histological assessment confirmed the selective nature of the liquid deposit in the submucosa. DISCUSSION: Plasma expanders produced cushions that initially increased in height but then remained constant for a longer period than cushions produced using glucose 50, gelatin, or isotonic saline solution. The combination of transmucosal jet application for elevation of the mucosa with plasma expanders is therefore an interesting approach to optimize endoscopic mucosal resections.

Selective fluid cushion in the submucosal layer by water jet: advantage for endoscopic mucosal resection.

BACKGROUND/AIM: Numerous new techniques have recently been reported and described for the endoscopic mucosal resection of large superficial lesions of the gastrointestinal tract. We present here for the first time the application of a water jet dissector for mucosa elevation. MATERIALS AND METHODS: In an ex vivo study, the effectiveness of a water jet dissector (Helix Hydro-Jet) placed directly on the stomach walls of 8 pigs was examined to create a mucosal elevation. After having determined optimal pressures, angle of application, and application times, 13 submucosal fluid cushions were produced in different areas of the stomach walls of 8 pigs in vivo, and the sizes of the resulting submucosal cushions were measured. RESULTS: Using pressures between 30 and 70 bar, it was routinely possible to create submucosal fluid cushions in the stomach wall ex vivo as well as in vivo. Histological examination showed a selective edema in the submucosa without damage to the deeper mucosal layers of the gastric wall. CONCLUSIONS: The capacity of a targeted high-pressure water jet to penetrate the mucosa and selectively create a fluid cushion in the submucosa facilitates endoscopic resection of the mucosa. This new method could contribute to ameliorate the endoscopic treatment of mucosal tumors which previously could not be resected endoscopically due to their size, extent, or location.

P300-mapping--a neurophysiological tool to quantify cerebral dysfunction after coronary artery bypass grafting.

Objective parameters are needed to quantify cerebral dysfunction following cardiac surgery in outcome and comparative studies. In this investigation we assessed the value of the late auditory evoked potentials N100 and P300 to measure the neuropsychological deficit after coronary artery bypass grafting (CABG). N100, an exogenous potential is influenced by the stimulus pattern (frequency, intensity and stimulus presentation rate). P300, an endogenous potential, depends on the cognitive processing invoked by the stimulus. With approval of the Human Investigation Committee and the patients' consents, 52 subjects undergoing elective CABG were enrolled. Operation, extracorporal circulation, anesthesia and postoperative intensive care were standardized. Twenty-channel recordings of N100 and P300 were obtained for off-line analysis. P300 was elicited using an oddball paradigm with rare target tones interspersed among frequent non-target tones. Additionally, neuropsychological tests (syndrome short test SKT and letter cancellation test) were carried out. Neurological examination and all tests were compared preoperatively and one week postoperatively. A significant deterioration in cerebral function was documented by the SKT score (P = 0.04), an increase in P300 latency (P = 0.004) and an increase of mistake rate in counting the P300 target tone (P = 0.02). No differences between preoperative and postoperative testing were found for letter cancellation, P300 amplitude and any N100 parameter. No correlation was found between the preoperative/postoperative changes in SKT score and P300 latency. P300 was proved to be an objective neurophysiological parameter that allows for the quantification of cerebral function after CABG.

[Suppression of the adrenal cortex by enoximone. A proband study with documentation of the hemodynamic course]. / Zur Frage einer Nebennierenrindensuppression durch Enoximon. Eine Probandenuntersuchung mit Dokumentation des hämodynamischen Verlaufs.

In contrast to the bipyridine derivatives amrinone and milrinone, the phosphodiesterase III/IV inhibitor enoximone is an imidazolone that creates the possibility of inhibiting adrenal steroid synthesis, as has already been demonstrated for other imidazoles, e.g. ketoconazole and etomidate. To clarify this point we carried out a double-blind sequential study in seven healthy volunteers. METHODS. After obtaining the approval of the ethics committee and the written consent of the volunteers, 1.25 mg/kg enoximone or saline was infused intravenously over a period of 20 min using a randomized crossover design with an interval of at least 5 days between the two trials. Twenty minutes after administration of the drug, 250 micrograms ACTH was injected. Plasma cortisol was measured prior to stimulation of the adrenal cortex and 30, 60 and 120 min afterwards; levels of aldosterone and 11-desoxy-cortisol were determined after 60 min. Standard radioimmunoassays were used. Haemodynamic parameters were measured non-invasively. RESULTS. In contrast to the placebo, enoximone resulted in a significant (P < 0.01) increase in the cardiac index (from 3.2 +/- 0.7 to 3.9 +/- 0.9 l min-1 m-2) and heart rate (from 69 +/- 11 to 81 +/- 8 min-1) and a decrease in peripheral resistance (from 1120 +/- 202 to 894 +/- 183 dyn s cm-5); blood pressure fell only slightly. Following injection of ACTH there were significant increases in cortisol (from 63 +/- 29 to 274 +/- 58 micrograms/l), aldosterone (from 86 +/- 37 to 300 +/- 105 ng/l) (both P < 0.001) and 11-desoxycortisol (from 5.3 +/- 1.2 to 9.8 +/- 4.6 micrograms/l; P < 0.05). There was no difference between enoximone and placebo at any time (P > 0.2). CONCLUSIONS. This study confirms the inodilation caused by enoximone. The normal response to ACTH rules out a direct inhibitory effect of a loading dose of 1.25 mg enoximone on the adrenal cortex. As the concentration of the major metabolite of enoximone, the sulphoxide, has been shown to surmount that of the parent drug after 40 min, this also holds true for the metabolite. We conclude that in contrast to etomidate, which causes a substantial reversible adrenal suppression after a single dose of 0.2 mg/kg, enoximone 1.25 mg/kg did not interfere with corticosteroid synthesis or release. Taking into account the metabolism and pharmacokinetics of this inodilator, there is no reason to expect an inhibitory effect even after repeated dosage.

[Postspinal headache. A comparison of the 24G Sprotte syringe and a 29G Quincke needle]. / Postspinaler Kopfschmerz. Ein Vergleich der 24G Sprotte-Kanüle mit einer 29G Quincke-Nadel.

PATIENTS AND METHODS: A randomised study was performed to compare the frequency of postdural puncture headache in 56 patients who underwent spinal anaesthesia for extra-corporeal shockwave lithotripsy using either a Sprotte 24 G (n = 28) or Vygon 29 G or Quincke type needle (n = 28). Frequency of headache was recorded in a similar group of 28 patients who received general anaesthesia. RESULTS: Dural puncture was easier with the Sprotte 24 G cannula than with the less stable Quincke needle, as documented by a significantly shortened time for insertion of the cannula (4.6 +/- 2.6 vs 8.6 +/- 6.3 min, P less than 0.005). The total frequency of post-operative headache was 57% in the Vygon 29 G group and 25% in the Sprotte 24 G group; 21% of patients in the general anaesthesia group complained of headache. Frequency of postdural puncture headache, classified as being posture-related, was 25% in the 29 G Vygon group, compared with 11% in the 24 G Sprotte group (P = 0.148). When only moderate and severe postdural puncture headache was considered, there was a significant difference (25% vs. 4%; P = 0.026) in favour of the Sprotte cannula. DISCUSSION AND CONCLUSIONS: Thus, the 24 G Sprotte needle was at least as effective as the 29 G Vygon needle, and there is a suggestion that the former is more effective in minimising the incidence of moderate or severe postdural puncture headache.

EEG and auditory evoked potential P300 compared with psychometric tests in assessing vigilance after benzodiazepine sedation and antagonism.

We have compared the EEG and auditory evoked wave P300 with psychometric tests in assessing vigilance after flumazenil antagonism of midazolam sedation in 12 healthy volunteers. Measurements were made before and after midazolam 0.1 and 0.2 mg kg-1 i.v., and immediately and 30, 60, 120 and 240 min after administration of flumazenil 1 mg. The sedative effects of midazolam and antagonism by flumazenil resulted in alterations in EEG, P300 and psychometric tests (syndrome short test, letter cancellation, choice reaction and recognition). However, 60 and 120 min after flumazenil a decrease in test performance indicating rebound sedation was seen only in P300 mapping. Thus P300 mapping was a sensitive method of detecting subtle differences in vigilance. Rebound sedation occurred even when midazolam 0.2 mg kg-1 was antagonized with an adequate dose of flumazenil. We suggest that it is advisable to supervise patients for at least 240 min after flumazenil antagonism of midazolam 0.2 mg kg-1.

[Atraumatic Clostridium septicum infection in granulocytopenia]. / Atraumatische Clostridium-septicum-Infektion bei Granulozytopenie.

A fatal Clostridium septicum infection occurred in three patients. Case 1. A 55-year-old man died of septicaemia resulting from granulocytopenia of uncertain aetiology; it was associated with perforation of ileal mucosal ulcers. Autopsy revealed neutropenic enterocolitis and diffuse gas formation, especially in the brain, caused by Clostridium septicum. Case 2. A 18-year-old boy developed a caecal invagination during imipenem-induced granulocytopenia. A fulminant postoperative Clostridium septicum infection ended fatally. At autopsy many ulcers were found at the site of invagination with gas formation involving all organs. Case 3. Myonecrosis of the left arm, caused by Clostridium septicum, developed without external cause in a 12-year-old girl with congenital neutropenia. Despite aggressive surgical intervention she died of toxic shock. Autopsy revealed caecal mucosal ulcers as the portal of entry of Clostridium septicum.

[Extrarenal elimination procedures in acute kidney failure]. / Extrarenale Eliminationsverfahren bei akutem Nierenversagen.

In spite of continuous progress in intensive care during the past two decades, there is no definite proof that the prognosis of critically ill patients with acute renal failure has actually improved. Nevertheless, the development of hemofiltration and hemodiafiltration and of the continuous methods has extended the therapeutic spectrum and allows therapy to be adapted to the specific cardiovascular and metabolic situation of the individual patient. Detoxification is carried out intracorporeally in peritoneal dialysis or extracorporeally by means of filters and membranes with different filtration properties. Peritoneal dialysis is seldom indicated in operative patients, because of its low efficiency and the hypercatabolism that is often observed, except in situations where continuous abdominal lavage is desired, as in peritonitis or necrotizing pancreatitis. The standard detoxification method is hemodialysis in which the filter is perfused in the opposite direction to blood flow. Solute transport is the result of diffusion, osmosis and, to a minor extent, convection, and the elimination of small molecules is favored. As huge amounts of dialysate have to be used, a central water regeneration unit is the technical prerequisite for hemodialysis. In critically ill patients bicarbonate dialysis should be preferred, because it is hemodynamically better tolerated. Hemofiltration relies on convection rather than diffusion through a membrane with a cut-off between 20,000 and 50,000 daltons. The ultrafiltrate largely resembles plasma water. Fluid loss is substituted by appropriate electrolyte solutions allowing space for negative balances and hypercaloric parenteral nutrition. Hemofiltration is better tolerated than hemodialysis and was introduced to improve the elimination of toxic middle molecules. In intensive care units without access to hemodialysis or intermittent hemofiltration continuous arteriovenous hemofiltration (CAVH), first proposed by P. Kramer, has become an alternative, mainly because of its simplicity and the absence of hemodynamic side effects. The drawback of this method is its limited efficiency. In hypercatabolic patients daily ultrafiltration rates of 10-15 l will not reduce blood urea sufficiently. The same holds true for severe hyperkalemia. One attempt to increase efficiency is predilution, which involves adding part of the substitution fluid before the filter, to enhance blood flow and to increase the effective filtration pressure by lowering the oncotic pressure of the plasma. Predilution will increase the net urea clearance by some 20%. Another way to enhance filtration is to apply negative pressure to the membrane with the aid of an infusion pump at the filtrate side. The development of better filters with smaller resistances may further increase filtration rates.(ABSTRACT TRUNCATED AT 400 WORDS)

[The estimation of blood circulation parameters using imaging techniques--comparison with measurements made using the Swan-Ganz catheter]. / Abschätzung von Kreislaufparametern mittels bildgebender Verfahren--Vergleich zu über den Swan-Ganz-Katheter ermittelten Messgrössen.

Circulation can be evaluated by means of measuring parameters in X-ray-thorax and ultrasonography. Changes in haemodynamics can be estimated by measured changes in width of vena azygos. Additional sonography of systemic veins of thoracic inlet (V. jugularis interna, V. cava inferior) improves multiple correlation to circulating blood volume up to r = 0.81. Supine or erect position and type of ventilation are influencing factors. Diaphragm motility was measured by means of ultrasonography: patients with assisted ventilation showed significantly decreased motility compared to patients with spontaneous breathing.

[ECG-controlled placement of central venous catheters in patients with atrial fibrillation]. / EKG-kontrollierte Plazierung zentralvenöser Katheter bei Patienten mit Vorhofflimmern.

Some workers state that sinus rhythm is essential for electrocardiographic placement of central venous catheters. We performed a prospective study to compare location control by ECG and by chest X-ray in 40 patients with absolute arrhythmia and atrial fibrillation. The criteria accepted as allowing the assumption of an intracardiac position of the catheter tip were: (1) Abrupt appearance of high-voltage P-waves when the right atrium (RA) was entered and their brisk disappearance when pulling the catheter back into the vena cava superior (VCS) and/or (2) a change in configuration and voltage of the QRS complex on withdrawal of the catheter from the right ventricle (RV). After establishment of an intracardiac position, the catheter was withdrawn until the ECG changed to show a trace identical to that seen before it had entered the heart. Then, in this study, the correct central venous position was confirmed by chest X-ray. The intravascular ECG revealed a correct placement of the catheter tip in the VCS in all patients but one. In this patient who had severe dysrhythmia, an intracardiac ECG could not be obtained, although the chest X-ray showed a correct position of the catheter in the VCS. While false-negative results (where an intracardiac catheter position cannot be documented although the catheter is in a central venous position) occasionally do occur, false-positive results (with ECG suggesting an intracardiac location read, though the catheter tip is actually in a peripheral vein) are virtually impossible.(ABSTRACT TRUNCATED AT 250 WORDS)